Licensed Professional Counselors

Name

Email Address

Phone Number

Best method of communication Best method of communication Email Address Phone Number

Preferred day of the week for appt. Preferred day of the week for appt. MondayTuesdayWednesdayThursdayFriday

Preferred time for appt. Preferred time for appt. MorningsEveningsAfternoons

Reason for seeking therapy

How did you hear about us? How did you hear about us?ReferralPsychology TodayMail

Will you be using EAP, insurance or self pay? Will you be using EAP, insurance or self pay? EAP Insurance Self Pay

If EAP or insurance, which provider will you be using?